What causes my nose to turn purple?

Purple Discoloration of the Nose

A purple nose is most commonly caused by visible venous congestion from allergic or vasomotor rhinitis, though serious vascular conditions like purpura fulminans must be excluded if accompanied by systemic symptoms.

Primary Differential Diagnosis

Benign Vascular Congestion (Most Common)

Allergic rhinitis causes venous pooling and congestion that can create blue-purple discoloration of nasal tissues, particularly visible in lighter skin types. 1, 2

• The nasal mucosa in allergic conditions appears pale, boggy, and edematous with increased venous stasis, which manifests as blue-grey to purple discoloration 1, 3
• "Allergic shiners" (blue-grey periorbital discoloration) occur in up to 60% of atopic patients due to venous stasis and are associated with nasal congestion 1
• Mucosal appearance can include pallor, edema, or hyperemia, with the blue-purple hue reflecting underlying vascular congestion 1, 2
• This discoloration is more apparent in individuals with lighter Fitzpatrick skin phototypes (I-III) where subcutaneous vessels are more visible 4

Vasomotor Rhinitis

• Pregnancy rhinitis and hormonal rhinitis cause vascular dilatation and increased blood volume, leading to nasal vascular pooling and potential purple discoloration 1
• Vasomotor rhinitis involves excessive cholinergic tone with prominent vascular changes 2

Normal Anatomic Variant in Children

• The transverse nasal root vein creates a blue linear discoloration on the nasal root in approximately 49% of children under age 6, more prominent in lighter skin types 4
• This benign vascular feature persists until at least age 6 and requires no treatment 4

Critical Red Flags Requiring Urgent Evaluation

Purpura Fulminans (Life-Threatening Emergency)

If purple discoloration is accompanied by fever, hypotension, or spreading purpuric lesions, purpura fulminans must be excluded immediately. 5

• This catastrophic condition begins with seemingly benign infection but progresses to purpuric ecchymosis, disseminated intravascular coagulation, and tissue gangrene 5
• Requires immediate resuscitation, correction of coagulopathy with heparin, and monitoring for compartment syndromes 5
• The presence of systemic symptoms (fever, malaise, spreading lesions) distinguishes this from benign nasal congestion 5

Systemic Granulomatous Diseases

• Wegener granulomatosis, sarcoidosis, and midline granuloma can affect nasal tissues with discoloration, typically accompanied by crusting, ulceration, or systemic symptoms 1
• These conditions present with additional findings beyond isolated purple discoloration 1

Diagnostic Approach

Key Historical Features to Elicit

• Timing and triggers: Seasonal variation suggests allergic rhinitis; constant symptoms suggest vasomotor or anatomic causes 1
• Associated symptoms: Sneezing, watery rhinorrhea, nasal congestion, and eye itching point to allergic rhinitis 1, 2
• Systemic symptoms: Fever, malaise, or spreading skin lesions require urgent evaluation for infectious or vascular causes 5
• Medication use: Topical decongestants cause mucosal hyperemia; ACE inhibitors and alpha-blockers can cause rhinitis 1

Physical Examination Findings

• Mucosal appearance: Pale, boggy mucosa with clear watery secretions suggests allergic rhinitis 1, 2, 3
• Vascular pattern: Blue-grey discoloration around eyes (allergic shiners) and nasal tissues indicates venous congestion from allergy 1
• Skin examination: Check for purpuric lesions, ecchymosis, or spreading discoloration that would indicate vascular emergency 5
• Vasoconstrictor test: Apply topical phenylephrine and re-examine after 5-10 minutes; edematous mucosa will shrink while polyps will not 1

Confirmatory Testing When Indicated

• Allergy testing: Skin prick testing or specific IgE immunoassays to identify allergic triggers if allergic rhinitis is suspected 1
• Complete blood count and coagulation studies: If any concern for purpura fulminans or systemic disease 5
• Nasal endoscopy: For persistent unilateral symptoms or concern for structural abnormalities 1, 2

Management Based on Etiology

For Allergic Rhinitis with Venous Congestion

• Intranasal corticosteroids are first-line therapy to reduce mucosal inflammation and venous congestion 3
• Environmental control measures: Remove bedroom carpeting, use foam pillows, enclose mattresses in plastic covers, keep windows closed, use air conditioning 3
• Second-generation oral antihistamines for additional symptom control with reduced sedation 3
• Avoid intranasal decongestants beyond 3-4 days to prevent rhinitis medicamentosa 1, 3

For Vasomotor Rhinitis

• Anticholinergic nasal sprays (ipratropium) are effective due to increased cholinergic tone 2
• Avoid triggers such as temperature changes, strong odors, and irritants 1

For Benign Anatomic Variants

• Reassurance that prominent transverse nasal root vein is benign and requires no treatment 4
• Typically fades with age and has no medical significance beyond cosmetic concern 4

Common Pitfalls to Avoid

• Do not assume all nasal discoloration is benign: Always assess for systemic symptoms that could indicate purpura fulminans or other serious conditions 5
• Do not rely solely on mucosal appearance: Mucosal color alone cannot distinguish allergic from nonallergic rhinitis; specific IgE testing is needed for definitive diagnosis 1, 2
• Do not prescribe prolonged topical decongestants: Use beyond 3-4 days causes rhinitis medicamentosa with rebound congestion and worsening symptoms 1
• Do not order sinus CT for isolated nasal discoloration: Imaging is not indicated without specific sinus symptoms like purulent drainage, facial pain, or suspected complications 6